Perspective

Gerontology & Geriatric Medicine

Volume 8: 1–14
Changing Hospital Care For Older Adults: The © The Author(s) 2022
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Case for Geriatric Hospitals in the United sagepub.com/journals-permissions
DOI: 10.1177/23337214221109005
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Joseph H. Flaherty, MD1 , Miriam B. Rodin, MD, PhD2, and John E. Morley, MBBCh2

Abstract
Hospital care of frail older adults is far from optimal. Although some geriatric models of care have been shown to improve
outcomes, the effect size is small and models are difficult to fully implement, sustain and replicate. The two root causes for these
shortcomings are competing interests (high revenue generating diseases, procedures and surgeries) and current hospital
cultures (for example a culture of safety that emphasizes bed alarms and immobility rather than frequent ambulation). Geriatric
hospitals would be hospitals completely dedicated to the care of frail older patients, a group which is most vulnerable to the
negative consequences of a hospitalization. They would differ from a typical adult hospital because they could implement
evidence based principles of successful geriatric models of care on a hospital wide basis, which would make them sustainable and
allow for scaling up of proven outcomes. Innovative structural designs, unachievable in a typical adult hospital, would enhance
mobility while maintaining safety. Financial viability and stability would be a challenge but should be feasible, likely through
affiliation with larger health care systems with other hospitals because of cost savings associated with geriatric models of care
(decreased length of stay, increased likelihood of discharge home, without increasing costs).

Keywords
hospital care, older adults, hospital culture, geriatric hospital, geriatric models of care

Introduction
Almost three decades ago, researchers identified that 32% of
those over age 70 and approximately 50% of those above age
80 lose physical function (activities of daily living) during a
hospitalization. The majority of these patients do not regain
this lost function (Sager et al., 1996). Only 44% of patients 85
years and older and 58% of patients 75–84 years old return
home after a hospitalization (Levant et al., 2015). Other
negative consequences associated with hospitalization in-
clude delirium, falls, pressure ulcers, catheter-associated
urinary tract infections (CAUTis) and adverse drug events
(ADEs) (Creditor, 1993; Wald, 2017). In addition to the
morbidity and mortality associated with these negative
consequences (Creditor, 1993; Wald, 2017), all of these are
associated with additional health care costs. Average 1-year
health care costs were 2.5 times higher among general
medical patients age 70+ with delirium compared to patients
without delirium (Leslie et al., 2008). Average hospital costs
were $20,327 higher among patients age 70+ who had de-
lirium after elective surgery (Gou et al., 2021). Based on a
meta-analysis, estimates of increased hospital costs per pa-
tient with a fall, pressure ulcer, CAUTI or ADE were $6,694,
$14,506, $13,793, and $5,746, respectively. (Agency for
Healthcare Research and Quality, 2017).
Several geriatric models of care have been developed to
prevent these negative consequences and have been shown to
1
Regional Medical Director of Geriatrics, Envision Physician Services, Dallas,
Texas, Division of Geriatrics, University of Texas Southwestern, Dallas,
Texas, USA
2
Division of Geriatrics, Department of Internal Medicine, Saint Louis
University, St Louis, Missouri
Corresponding Author:
Joseph H. Flaherty, MD, Regional Medical Director of Geriatrics, Envision
Physician Services, Dallas, Texas, Division of Geriatrics, University of
Texas Southwestern, 13737 Noel Rd, Suite 1600, Dallas, TX, 75240, USA.
Email: joseph.Flaherty@envisionhealth.com

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2 Gerontology & Geriatric Medicine
improve outcomes such as increased likelihood of discharge
home instead of a facility, decreased incidence of delirium,
decreased mortality risk, shortened hospital length of stay
(LOS) and lower or equal costs of hospital care. (Ellis et al.,
2017; Van Creen et al., 2010; Baztán et al., 2009; Hshieh
et al., 2015; Grigoryan et al., 2014; Kavalieratos et al., 2016).
These models have their greatest impact on frail older patients
(Gilbert et al., 2018; Gillick, 2014; Searle & Rockwood,
2018). Despite these positive outcomes, these models have
not been widely implemented throughout adult hospitals
(Clark, 2013; Palmer, 2018). Geriatric hospitals would be
hospitals completely dedicated to the care of frail older pa-
tients, a group which is most vulnerable to the negative
consequences of a hospitalization. They would differ from
typical adult hospitals because they could implement evi-
dence based principles of successful geriatric models of care
on a hospital wide basis, which would make them sustainable
and allow for scaling up of proven outcomes.
The aims of this article are to (1) review successful ge-
riatric models of care, describe their positive outcomes and
their limited size effect; (2) discuss why it is not possible to
fully implement the principles of geriatric models in US adult
hospitals; (3) delineate why geriatric hospitals would be the
best option to implement these principles and how they would
do this; and (4) discuss challenges of implementing this
model of hospital care.
Current Geriatric Models of Care
In older adults, the combination of diseases, syndromes and
psychosocial problems creates a clinical situation that is
different from most single organ subspecialties, so that ge-
riatric medicine developed assessments and interventions to
address all of these. Assessments began with the Compre-
hensive Geriatric Assessment (CGA) (Matthews, 1984),
followed by models of care such as Geriatric Evaluation and
Management Units (GEMUs) (Rubenstein et al., 1984),
Geriatric Special Care Units (Collard et al., 1985) and Acute
Care of the Elderly (ACE) Units (Landefeld et al., 1995).
Subsequent models which pertain to hospitalized older
adults, included delirium prevention (Inouye et al., 1999), and
management models (Flaherty et al., 2003), orthopedic-
geriatric models (Zuckerman et al., 1992; Khasraghi et al.,
2005), palliative care (Carlson et al., 1988), trauma-geriatric
models (Fallon et al., 2006) and geriatric emergency de-
partments (Hogan et al., 2014).
The core principles of early geriatric models of care in-
clude CGA (which identifies geriatric syndromes and psy-
chosocial problems in addition to medical conditions,
especially among frail older adults), (Stuck et al., 1993) a
geriatric-focused interdisciplinary team (for example, nurses,
therapists, and social workers with special interest or training
in geriatrics, as well as a geriatrician), and early discharge
planning (Rubenstein et al., 1984; Collard et al., 1985;
Landefeld et al., 1995). Later models have focused on specific
syndromes or clinical scenarios for which frail older patients
are particularly vulnerable (Inouye et al., 1999; Flaherty et al.,
2003; Zuckerman et al., 1992; Khasraghi et al., 2005; Carlson
et al., 1988; Fallon et al., 2006; Hogan et al., 2014).
Based on meta-analyses, several of these models have
been shown to improve outcomes (Ellis et al., 2017; Van
Creen et al., 2010; Baztán et al., 2009; Hshieh et al., 2015;
Grigoryan et al., 2014; Kavalieratos et al., 2016). Table 1
describes the two most positive outcomes [defined as best
odds ratios (ORs), relative risks (RRs) or standard mean
differences (SMDs)] with other outcomes analyzed by meta-
analyses reported under the last column as “significantly
different” or “not significantly different.” CGA improves
likelihood of being alive and living at home at discharge and
at the end of the follow up period (Ellis et al., 2017). GEMU
reduces institutionalization and functional decline (Van Creen
et al., 2010). Various models of acute geriatric units, which
include ACE Units, increase odds of living at home at dis-
charge and 3 months after discharge (Baztán et al., 2009).
They also decrease risk of functional decline during hospi-
talization, and reduce costs of hospital care (Baztán et al.,
2009; Fox et al., 2012; Palmer, 2018). Delirium prevention
studies reduce incident delirium and falls (Hshieh et al.,
2015). Orthopedic-geriatric models reduce mortality during
hospitalization and at 6–12 months follow up, as well as
decrease hospital LOS (Grigoryan et al., 2014).
Table 1 also reports the total number (and percentage) of
events for intervention and control groups in aggregate, for
each meta-analysis. Despite these positive outcomes, there
seems to be a limited size effect and not all outcomes were
affected. Several reasons for this have been hypothesized by
the authors of the meta-analyses: inclusion of patients for
whom the outcome would not have happened anyway (lack of
targeting highest risk patients), difficulty in implementation
and compliance of all components of multicomponent
models; financial and time constraints; inability to control for
confounding factors; and complexities of care processes in
hospitals beyond what is involved in the model (Ellis et al.,
2017; Van Creen et al., 2010; Baztán et al., 2009; Hshieh
et al., 2015; Grigoryan et al., 2014). The reason this is im-
portant is that a geriatric hospital based on principles in these
geriatric models of care has the potential to address some of
these problems. For example, a geriatric hospital may be
better equipped to implement all components of these models
and maintain compliance since the foundational goals of the
hospital are to improve outcomes similar to these studies, for
every patient.
Another reason in support of geriatric hospitals is that
these models have not been widely implemented throughout
adult hospitals (Clark, 2013; Palmer, 2018). Various reasons
for low implementation rates of these models include the
following: replication in the real world involves many more
steps than a short-term study; not enough buy-in from hos-
pital administration or front-line nurses and physicians;
complexities and priorities of other services within hospitals;
Flaherty et al. 3

Table 1. The effects of various geriatric models of care based on published meta-analyses (where available)

Odds ratios (OR), Relative Risks (RR) or

Model of Care Standardized Mean Differences (SMD) Other outcomes that were significantly
Author, year with 95% Confidence Intervals (95% CI) different from Usual care/Control group (+)
Total number of studies Number of events, (%) in Intervention or Not significantly different from Usual care/
in meta-analysis Two most positive outcomesa and Usual care/Control groups Control group ( )

Comprehensive Alive and living at home at end of OR = 1.06 (1.01–1.10) (+)b

geriatric assessment follow up, 3–12 months (n = 16 Intervention: 2079/3498, 59.4% Alive and living at home (discharge)
(CGA) studies analyzed) Usual care: 1852/3301, 56.1% Admission to nursing home (discharge)
Ellis, 201715 Admission to a nursing home at OR =.80 (0.72–0.89) Death or deterioration
N = 29 studies end of follow up, 3–12 months Intervention: 481/3224, 14.9% Cognitive function
(n = 14 studies analyzed) Usual care: 568/3061, 18.3% ( )
Mortality at end of follow up, 3–12 months
Dependence
Death or dependence
Activities of daily living
Length of stay
Readmission
Geriatric evaluation and Institutionalization at 12 months RR = 0.78 (0.66–0.92) (+)
management unit (4 studies analyzed) Intervention: 212/1423, 14.9% None
(GEMU) Functional decline at hospital Control: 264/1438, 18.4% ( )
Van Craen, 201016 discharge (2 studies analyzed) RR = 0.87 (0.77–0.99) Mortality at 3 months
N = 7 studies Intervention: 306/1043, 29.3% Mortality at 6 months
Control: 342/1021, 33.5% Mortality at 12 months
Institutionalization at 3 months
Institutionalization at 6 months
Functional decline at 12 months
Hospital readmission
Length of stay
Acute geriatric units Living at home at hospital OR = 1.30 (1.11–1.52) (+)
Baztan 200917 discharge (5 studies analyzed) Intervention: 1229/1588, 77.4% Functional decline at discharge
N = 11 studies Living at home 3 months after Control: 1403/1962, 71.5% Cost of admission
discharge (4 studies analyzed) OR = 1.16 (0.99–1.37) ( )
Intervention: 972/1356, 71.7% Admission to nursing home at discharge
Control: 992/1457, 68.1% Admissiion to nursing home 3 months after
discharge
Case fatality
Readmission at 3 months
Delirium prevention Incident delirium (7 studies OR = 0.47 (0.39–0.58) (+)
Hshieh 201518 analyzed) Intervention: 129/1729, 7.5% None
N = 7 studies (4 medical, Falls (4 studies analyzed) Control: 301/2022, 14.9% ( )
3 surgical) OR = 0.38 (0.25–0.60) Institutionalization
Intervention: 24/519, 4.6% Length of stay
Control: 95/519, 18.3% Change in functional status
Change in cognitive status
Orthopedic- geriatric Inpatient mortality (9 studies RR = 0.60 (0.43–0.84,) (+)
Gregoryan 201420 analyzed) Intervention: 91/1694, 5.4% Length of stay
N = 18 studies Mortality at 6–12 months Control: 149/1639, 9.1% ( )
(11 studies analyzed) RR = 0.83 (0.74–0.94) Time to surgery
Intervention: 348/2274, 15.3%
Control: 703/4031, 17.4%
Palliative carec Quality of life at 1–3 months SMD = 0.46 (0.08–0.83) (+)
Kavalieratos 201619 (15 studies analyzed; only 2/15 SMD = 0.66 ( 1.25 to 0.07) Symptom burden at 4–6 months
N = 43 included in RCTs were hospital based) ( )
review; 23 included in Symptom burden at 1–3 months Quality of life at 4–6 months
meta-analyis (10 studies analyzed; only 1/10 Survival
RCTs was hospital based)
Geriatric emergency No meta-analysis available
department
Trauma-geriatric No meta-analysis available
a
For the sake of space, only the two most positive outcomes [defined as best odds ratios (ORs), relative risks (RRs) or standard mean differences (SMDs)] for
each meta-analysis are reported here, with other outcomes analyzed by meta-analyses reported under the last column, “significantly different” or “not
significantly different.”
b
Meta-analysis by Ellis did several analyses based on subgroups, for which this table does not have space. For example, Ward versus Team approach of CGA,
targeting (needs-related vs. age-related criteria for admission to study); and timing of admission (for example, direct admission vs. stepdown vs. acute admission).
c
For palliative care, there were several different instruments used to evaluate quality of life and symptom burden, so pooled results were summarized as
standardized mean differences (SMDs).
4 Gerontology & Geriatric Medicine
lack of leadership; lack of champions; shortage of geriatri-
cians; market forces and ageism (Clark, 2013; Flaherty &
Little, 2011; Inouye et al., 2006; Palmer, 2018; Rubin et al.,
2011).
We propose that there are at least two root causes of why it
is not possible to fully implement the principles of geriatric
models in US adult hospitals: competing interests and too
many different hospital cultures.
Competing Interests
Competing interests stem from several areas. Hospital Chief
Financial Officers and other financial managers know that
certain service lines generate more revenue than others, such
oncology, cardiology or gastroenterology, or the surgical
programs such as elective orthopedics and cardiothoracic
surgery (Ellison, 2018; Butcher, 2102). Although leadership
in hospitals may recognize the importance or even support
geriatric-based concepts of care, these models have difficulty
financially competing with higher revenue programs.
(Palmer, 2018)
Another indirect source of competing interests comes as a
result of frail older patients being cared for on different units
throughout the hospital, rather than on one unit where staff
can be trained with a focus on geriatric assessments and
protocols. Although hospitals could train staff on cardiology
units or neurology units for example, this makes trying to
implement and maintain use of protocols and principles of
geriatric models of care difficult. Another key component of
models like the ACE Unit include a specialized environment
that promotes mobility and safe patient self-care. Studies
have shown more success of the ACE Unit model when it is
located on one specialized unit with dedicated staff compared
with ACE-like care for older patients on several different
units (Flood et al., 2018). This idea of having more success
with a geriatric model of care if it is done in one location is
also evident from studies about orthopedic-geriatric models
of care (Grigoryan et al., 2014).
Too Many Different Hospital Cultures
Hospitals have many different cultures of the way they care
for a variety of patients and their acute illnesses. Cultures are
important as they can create an environment to help em-
ployees know what is expected of them and what is important
(Strasser et al., 2002). Although hospital cultures can have
positive impact on the patient experience, patient safety and
patient outcomes (Shaw, 2002), they can also lead to negative
consequences for frail older patients who might not fit into
that unit’s culture of care (Shaw, 2002; Khokher et al., 2009).
For example, cardiology units and neurology units utilize
important protocols that decrease variation and improve
outcomes. However, if a frail older patient with a urinary tract
infection and delirium is on one of these units, every 2 hour
vital signs or neurological checks throughout the night (usual
culture of care) could disrupt sleep leading to worsening of
delirium.
Another hazard older patients face is that they are at risk of
being considered a homogenous high-risk group for hospital
associated adverse events, which creates potentially harmful
blanket approaches. For example, bed alarms for fall risk,
which limit mobility and disrupt sleep wake cycles, are
implemented based on protocols which use older age as a
major risk factor for falls (Growden et al., 2017). Another
example is the use of physical restraints to prevent patients
from pulling on lines, tubes or telemetry monitors before
considering alternatives to restraints (Sullivan-Marx et al.,
2003; Cosper et al., 2015; Tolson & Morley, 2012) or trying
to discontinue what the patient is pulling on (Flaherty &
Little, 2011).
Table 2 describes several other examples of typical hos-
pital processes that have created a culture of how we care for
all acutely ill adults. For frail older patients, these may di-
rectly or indirectly lead to negative consequences already
discussed above. Some of these usual care processes include
early morning blood draws, restricted diets, fasting protocols,
hospital gowns and an expectation that older patients need
discharge to a facility rather than home.
One of the most important reasons that usual hospital
culture is a barrier to implementing geriatric principles and
models of care is that when a culture change is necessary, as is
the case for geriatric models, it may be the most difficult part
of a hospital to change. Culture was the number one response
in a survey of senior health care executives when asked about
major barriers for creating an effective patient experience.
(Commins, 2013). The ACE Unit is an example of a geriatric
model of care that requires a major cultural change (Palmer,
2018).
Geriatric Hospitals: Changing Typical
Processes of Care and Developing
Innovative Structural Designs
As long as these two root causes exist, (competing interests
and cultures that distract focus away from needs of frail older
patients), geriatric models of care and the principles upon
which they are based will never be fully implemented and
their full potential to have a positive impact will not be seen.
Geriatric hospitals, dedicated solely to the care of frail older
patients, would be different from adult hospitals because they
could change typical processes of care on a hospital wide
basis to fit the needs of frail older patients and develop in-
novative structural design, also on a hospital wide basis, in
order to enhance mobility while maintaining safety.
Changing typical processes of care
Table 2 lists possible solutions for changing typical hospital
processes. Geriatric hospitals, unlike adult hospitals, have the
Flaherty et al.
Table 2. Examples of typical hospital processes that have created a culture of how we care for acutely ill older adults, and possible solutions
for change
Processes
Admission processes
Patients from home, facilities or clinics
ED processes
Use of typical gurneys, wait times, typical triage processes
(prioritization), competing interests
Physician-centered routines or physician-based processes
Tradition or routine of early morning rounds by physicians
Bed rest or other restricted mobility orders by physicians
Required physician order for physical therapy, occupational
therapy or speech therapy
Early morning blood tests Need for frequent blood tests
Admission diet orders delayed or restricted diet ordered
Nurse processes
Fasting (“NPO”) before procedures or surgeries
Nurse:patient ratios and nurse assignments are typically based on Although older patients are not a homogenous group, not having
having some patients with heavier or lighter care needs than
others This can create variation from day to day
Routine vital signs and overutilization of vital signs
Routine medication times based on nurses’ schedules and
availability/prioritization of tasks
5
Possible solutions for change
Set up admission processes that avoid the ED, such as use of
telemedicine or internet applications to communicate with patients
and providers at home, facilities and clinics to expedite triage
decisions
Geriatric EDs are becoming more common
Other ideas
Develop protocols/pathways for quicker admission processes With the
presence of hospitalists, could some subset of patients be evaluated
on various wards or locations within various wards, thus bypassing
ED?
Was once necessary for physicians who had outpatient clinic
responsibilities
Use of hospitalists allows for changing the time of patient rounds
This has potential for a better assessment (mid-morning, patients may
be more alert and out of bed for functional assessment)
Protocols for immediate baseline assessment and evaluation of mobility
status; highest possible level ordered by interprofessional team
member, usually therapist
Develop protocols/pathways that a medical director of a floor could
sign
Develop screening done by these therapists that allow them to improve
efficiency of patients being seen
This would need oversight and monitoring
Mobility teams for daily ambulation instead of relying on therapists for
daily ambulation/mobility
Adjust times to meet patients’ needs
Examine and modify current internal medicine practices related to
frequent blood tests (e.g. CBC every 6 hours for suspected bleeding;
cardiac enzymes every 8 hours for suspected myocardial inschemia)
Protocols for immediate baseline assessment and evaluation of
nutrition and swallowing status; highest possible level ordered by
interprofessional team member
Individualize for patients and procedures
Critically analyze current routines
Early recovery after surgery protocols already limit this practice
Could geriatric hospitals develop further protocols for safely limiting
current fasting procedures?
younger adult patients in the equation for nurse patient ratios may
allow for more consistent determination of needs
This may also allow for developing new ideas to typical nurse:patient
ratios
For example, increasing nurse aides with more care responsibilities
instead of registered nurses
Use of “non-touch” technology to monitor RR and HR and T
Individualize vitals sign frequency
Avoid middle-of-the-night vital signs when appropriate
Individualize medication times to match what the patient does at home
Individualize patient care plans to allow self-administration of certain
medications
(continued)
6 Gerontology & Geriatric Medicine

Table 2. (continued)

Processes Possible solutions for change

“Sitters” or one-to-one observers Enhance training of these “care partners” who are the constant eyes
and ears on the patient and who could implement mobility programs
and other geriatric-based protocols
Bed alarms Close constant observation
Wireless technology
Direct patient care processes
The bed as the center of the room The bed as the primary location Develop patient rooms where bed is not the center
for patient care Develop or create ways to give care outside the bed. (e.g. IV treatments
in a chair)
Sleep schedules that are not similar to home and lack of healthy Night time sleep is a priority
sleep environment Individualize sleep schedules
Modify routine care to avoid sleep disruptions
Routine meal times Suboptimal quality of meals, lack of preference Individualize meal times to match what the patient does at home
for what older person might want Small kitchens where food is available and can be prepared anytime
Expectation that families bring food from home
Hospital gowns Gowns add to dehumanizing effect of the hospital Use of gowns that are more dignified
and may add to sick behavior Use of a variety of gowns to give patients choice
Discourage use of gowns; encourage use of patients’ usual clothing
Not allowing the family or significant others to be involved in Involve family as part of the health care team from admission
direct patient care Would include some basic training and consent process
Could be useful for basic activities such as feeding, bathing, toileting
Adverse events (AEs) of older adults are diluted because hospital Although “higher” rates seem contradictory to improvement, having
rates are based on all inpatients, most of whom are adults higher rates creates an importance to these AEs for which focused
younger than age 65 years, who’s risk for AEs is very low (e.g. interventions targeted at a higher risk population can be done to
catheter-associated urinary tract infections, adverse drug lower rates
events, falls with injury) These lower rates could become new age-based goals for other adult
hospitals
Indirect patient care processes
Transportation around the hospital Use this as an opportunity
Getting outside of the hospital room could have health benefits
Transporters could play an important role in this if they receive training
in geriatric principles
How patients are scheduled for procedures tests or surgeries Develop scheduling systems based on factors such as frailty or risk of
Usually first come first serve, or no apparent process delirium, especially if procedures absolutely require NPO
Division of labor for jobs in hospital Consider education and training of any employees that have any type of
contact with patients
For example, housekeeping employees could be trained on how to
interact with people who have dementia or delirium
Traffic into and out of the patients room is random and not Limited access to patient rooms; for example, housekeeping only
monitored during times when patient is not in room
Close monitoring through windows
Having staff stay in a room is different than staff entering/leaving a room
frequently
Discharge processes
Perception that discharge to post-acute care is common and Many hospitals understand the benefit of starting discharge planning
expected early
Could be done day one, with an emphasis on “our hospital’s goal is to
help people return home after a hospitalization. Is that your goal?"
Discharge follow up not standardized Develop standardized protocols for follow up based on geriatric based
goals identified in studies of geriatric models of care (such as
function, return to home)
Develop systems that follow the patient for extended periods (e.g.
3 months, or even 1 year)

Abbreviations: ED, emergency department; IV, intravenous; CBC, complete blood count; NPO, latin for “nil per os” meaning nothing orally; RR, respiratory rate;
HR, heart rate; T, temperature
Flaherty et al.
potential to widely implement these changes because all
hospital processes would be planned and carried out with the
needs of frail older patients in mind. A critical piece to
carrying out these changes on a hospital wide basis is that job
descriptions of everyone working in the hospital should in-
clude some type of responsibility related to the processes that
help frail older adults return to their pre-illness functional
level. This also requires that everyone directly involved in the
care of the patient to know the patient’s baseline function
before the acute illness. The goals of the interprofessional
teams would become more clear and accurate, leading to
better decisions about the inpatient treatment and discharge
plans (Rosen et al., 2018).
Implementing these changes also need to be based on
principles of successful geriatric models. For example, there
would be an emphasis on goals similar to geriatric models of
care such as prevention of delirium instead of lack of
awareness of delirium (Hshieh et al., 2015) and returning
home instead of an assumption that most patients need skilled
nursing facilities after hospitalization (Tolson & Morley,
2012).
Geriatric hospitals must meet the highest standards of care
while meeting the individual needs of frail older adults.
Critical thinking encourages the use of best practices while
allowing for individual care to avoid harm (Heffner & Rudy,
2008). This is an essential component of the modern
movement toward patient centered (P4) care (Morley &
Vellas, 2017). A geriatric hospital would allow for usual
care processes to be scrutinized for risks versus benefits.
Examples include early morning blood draws, vital signs that
interrupt sleep, fasting protocols before surgery and frequent
unnecessary blood sugars. (Gustafsson et al., 2019; Tóth
et al., 2020; Warnock & Latifi. 2022).
A major challenge in the care of frail older patients is the
ability of staff, especially nurses, to give adequate care for this
vulnerable population, in the context of how inadequate
nurse:patient ratios can affect patient outcomes (Driscoll
et al., 2018). There are several reasons why geriatric hos-
pitals should be able to handle this staffing challenge. First,
successful geriatric models of care such as ACE Units,
orthopedic-geriatric models and delirium prevention models
have shown improved outcomes without a change in the
nurse:patient ratios (Counsell et al., 2000; Bhattacharyya
et al., 2013; Rubin et al., 2011). Second, interdisciplinary
team work can make care more coordinated so there is less
duplication and more efficiency (Bauer et al., 2009). The third
reason is related to missed nursing care, the concept that
required patient care during a nurse’s shift is omitted or delayed
(Kalisch et al., 2009). While a geriatric hospital might not be
able to increase nurse:patient ratios, it would be able to change
many of the factors affecting missed nursing care among frail
older patients. In one study, researchers identified lack of
managers’ competence in establishing care guidelines, negative
attitudes towards frail older adults, weakness in interdisciplinary
care and lack of knowledge, skills, and experience of nurses in
7
dealing with frail older patients as reasons for missed nursing
care (Rezaei-Shassavarloo et al., 2021). These areas of concern
are some of the strengths of many geriatric models of care (Ellis
et al., 2017; Van Creen et al., 2010; Baztán et al., 2009; Hshieh
et al., 2015; Grigoryan et al., 2014). Lastly, studies of geriatric
models of care have shown higher satisfaction of staff, including
nurses, compared to usual care (Counsell et al., 2000;
Bhattacharyya et al., 2013; Rubin et al., 2011).
Developing innovative structural designs
Innovation in structural design should follow two key
principles. First, based on successful geriatric models of care
(Van Craen et al., 2010; Baztan et al., 2009), an environment
should be created that helps avoid time in bed and enhances
and encourages mobility and self-care. Although we have
known for almost a century about the dangers of bed rest
(Asher, 1947), there has been little progress in developing
interventions to address this problem (Brown et al., 2016).
The bed continues to physically be the center of the patient
room and from a culture of care perspective, the center of the
care we give. There are several opportunities for innovation in
this area. One option would be to remove the bed during non-
sleeping hours by using a Murphy-type bed that folds up into
the wall. An additional strategy would be to have an indi-
vidualized specific goal for time out of bed, based on pre-
illness time spent out of bed. Although ill patients need extra
rest, what is lacking is an acceptable individualized goal for
patients. While there are no clear data to guide physicians, a
specific amount of time in bed and out of bed may be the first
step towards developing research in this area. Even among
hospitalized older adults in their 80s and 90s, individualized
moderate-intensity resistance, balance, and walking exercises
are feasible and effective (Martı́nez-Velilla et al., 2019).
Walking paths on units or walking programs, not just
physical therapy, would be expected (Brown et al., 2016).
Central dining areas, already a part of most ACE Units would
also be needed (Palmer, 2018). For patients who do not prefer
community or common dining, chairs and tables in the rooms
can be used. Over-the-bed tables promote time in bed and
increase risk of aspiration, so should not be a part of geriatric
hospitals (Manganelli et al., 2014; Ishii et al., 2022).
The second key principle for innovation is the need to
design environments with patient safety in mind. One major
safety concern in hospitals is the risk of fall injury. Two
examples of innovation here include dual stiffness floors
which may reduce fall related injuries (Knoefel et al., 2013)
and, since almost half of falls occur in and around the
bathroom (Tzeng, 2010), use of automated sliding doors or
replacing the doors with curtains, as long as privacy could be
maintained, could make toileting easier and safer.
Another major safety concern for hospitals is related to the
care of patients with delirium. These patients are very high
risk for falls, sometimes require physical restraints or med-
ications to control behaviors, can pull on lines or tubes
8 Gerontology & Geriatric Medicine
Figure 1. Architectural example of semicircular units within a geriatric hospital.
necessary for care, and often need extra nursing time or even
one-to-one sitters (Marcantonio, 2011). One innovative
strategy is to design hospital rooms or units that allow for
close observation without significantly increasing staff. This
has been done using a model called the Delirium Room. The
original model is an open 4-bed room, with dividing curtains
for privacy. The care in the room is completely free of
physical restraints, emphasizes non-pharmacological man-
agement of delirium, and utilizes patient care techs, trained to
be active caregivers (instead of sitters), one of whom is al-
ways in the room. It has been shown to prevent loss of
function and may have a positive effect on hospital LOS
(Flaherty et al., 2010). This model has been replicated uti-
lizing a 6-bed unit as part of an inpatient geriatrics program
with a focus on older patients with any type of cognitive
impairment (Flaherty et al., 2021). Another model of a
Delirium Room in Singapore utilizes a central area within the
room for activities and is also restraint free. It has been shown
to improve function, decrease duration of delirium and de-
crease hospital LOS. (Chong et al., 2014).
Other options for structural design to enhance close ob-
servation would be semicircular units which allow those
outside the rooms, but not inside, to see into all of the rooms
from a central location. An architectural example of semi-
circular units within a geriatric hospital is seen in Figure 1.
This structural design of a more efficient layout may help
improve factors associated with missed nursing care by de-
creasing time spent walking between patient rooms in long
hallways and increase time spent directly observing patients
(Rezaei-Shahsavarloo et al., 2021). This open design may
also assist efforts and improve attitudes towards reducing
restraints (Gunawardena & Smithard, 2019).
Challenges
One of the first challenges geriatric hospitals may have is to
figure out which older patients they should care for. As noted
in the introduction, a geriatric hospital would have as its
focus, the needs of frail older patients. The term frail is
important for several reasons. It is a comprehensive term that
encompasses most factors and characteristics associated with
both the risk of negative consequences of hospital care and
the likelihood of benefiting from principles of geriatric
models of care (Gilbert et al., 2018; Gillick, 2014; Searle &
Rockwood, 2018). Most studies on geriatric models of care
used age instead of frailty as inclusion criteria, which allowed
many older non-frail patients in, who would have had similar
outcomes with usual care (Van Creen et al., 2010; Baztán
et al., 2009; Hshieh et al., 2015; Grigoryan et al., 2014).
Frailty is a well known entity (Fried et al., 2001) and many
validated tools exist to identify this syndrome (Hewitt et al.,
2018; Jørgensen & Brabrand, 2017; Warnier et al., 2016).
Thus, it could be used as a screening criteria for which older
adults with acute illnesses should be admitted to a geriatric
hospital and which should be admitted to a typical adult
hospital.
Another way to identify older patients who would benefit
from geriatric hospitals is to screen for certain geriatric
Flaherty et al.
syndromes when older patients present with an acute illness.
The most common geriatric syndromes among older patients
coming to emergency departments in addition to frailty are
dementia, delirium and falls (Carpenter & Mooijaart, 2020).
The presence of these syndromes alone should not be reason
enough for admission. However, the presence of both an
acute illness justifying hospital care and geriatric syndromes
could guide triage decisions about which patients need a
geriatric hospital.
Another approach is to develop a list of certain conditions
or illnesses that might benefit from principles of care based on
geriatric models. However, there is no evidence that the
medical treatment for some of the most common diagnoses
such as heart failure, pneumonia or urinary tract infections
(Agency for Healthcare Research and Quality, 2018) was any
different in the geriatric models of care compared to usual
care (Van Creen et al., 2010; Baztán et al., 2009; Hshieh et al.,
2015; Grigoryan et al., 2014).
One final approach to consider is to use a higher age cutoff
(e.g. age 80+) which would capture a population with enough
high risk patients that positive outcomes could still be
demonstrated (Sanford et al., 2020).
Another challenge is that geriatricians are in short supply.
Thus it would be unlikely that there would be enough to cover
all inpatient services. Specialized training for a new category
of geriatric hospitalists may need to be developed (Sinvani
et al., 2018).
Which services and which specialties geriatric hospitals
require would need to be considered. Interventional radiology
and surgical services such as orthopedics, trauma, and general
surgery would likely be necessary (Mrdutt et al., 2019).
Vascular surgery and urology services would be helpful
(Drach & Griegling, 2003; Partridge et al., 2015). Based on
the most common diagnoses for inpatient stays among pa-
tients age 75+ (Agency for Healthcare Research and Quality,
2018), neurology and common internal medicine subspe-
cialties that adult hospitals have to offer would also be
needed.
If a geriatric hospital has intensive care unit (ICU) beds,
their associated outcomes should be carefully assessed. One
study showed that a higher number of ICU beds increased use
of mechanical ventilation among patients with dementia, but
did not improve outcomes (Teno et al., 2016). The potential to
overuse ICUs would have to be balanced with the negative
aspect of not having them for older patients who become
critically ill and would require transfer to another hospital
with ICU services.
Financial viability and stability would be a challenge but
should be feasible. It is likely that geriatric hospitals will have
to be affiliated with a health care system that has other
hospitals, rather than be independent entities. Although ge-
riatric models of care do not generate revenue, they could
help with cost savings. For example, frail older patients
compared to non-frail older patients have longer average LOS
and more often are discharged to post-acute care facilities
9
(Simpson et al., 2018; McIsaac et al., 2016; Fuertes-Guiró &
Velasco, 2020; Evans et al., 2014). If geriatric hospitals can
target this population and concentrate efforts in one location,
they could scale up the outcomes associated with successful
geriatric models of care such as decreasing LOS and im-
proving likelihood of returning home, without increasing
costs (Grigoryan et al., 2014; Palmer, 2018; Zaubler et al.,
2013).
Over utilization of tests and treatments puts frail older
patients at particular risk for harm (American Geriatrics
Society, 2021; Chalmers et al., 2021; Hajjar et al., 2005;
Kouladjian et al., 2014; Wald, 2017) and increases the costs
of medical care (Chalmers et al., 2021). Geriatric hospitals
would offer the best opportunity to address this problem
because they could more easily monitor utilization and de-
velop standards for frail patients since all of the patients are
frail. For example, hospital wide standards could be devel-
oped concerning appropriate use of percutaneous gastric
feeding tubes for patients with advanced dementia (American
Geriatrics Society, 2021). A strong palliative care program
would be necessary since they have been shown to reduce
costs while improving patient quality of life and symptom
burden (Kavalieratos et al., 2016; Morrison et al., 2008).
Reimbursement is moving towards value-based care (Pay
for Performance) (Zaresani & Scott, 2021). Geriatric hos-
pitals, if modeled after successful geriatric models, should be
able to do this better than typical adult hospitals. Also, health
care systems that participate as an Accountable Care Orga-
nization with bundled payments may find geriatric hospitals
beneficial since some of the cost savings with geriatric
models of care can occur after discharge, for example related
to increased likelihood of discharge home instead of a facility
and reduced readmission rates (Deschodt et al., 2013; Flood
et al., 2013; Navathe et al., 2021; Palmer, 2018).
Choosing the right size for geriatric hospitals may be a
challenge, but starting smaller would probably be prudent. In
2019, there were over 6000 registered hospitals in the US.
More than half of the hospitals had less than 100 beds, and
one-third had less than 50 beds. This suggests that small
hospitals can be financially viable (Michas, 2021).
Setting New Standards
Geriatric hospitals have the potential to set standards or
benchmarks for many of the outcomes mentioned above that
geriatric models have examined (such as percentage of pa-
tients returning home or delirium incidence). They also have
the potential to set either age-based or frailty-based goals, as
opposed to adult hospitals, that lump all patients into quality
data. This lumping “dilutes” the actual rates for older patients
for areas such as infections (CAUTIs, hospital acquired
pneumonia, central line infections), DVTs/PEs, pressure ul-
cers, 30 day readmissions and mortality (Agency for
Healthcare Research and Quality, 2017). Data like this
10
may encourage adult hospitals to use data from geriatric
hospitals as benchmarks for older patients in their hospital.
Conclusion
Although several successful models of care exist for hospi-
talized older adults, their effect size is small and the models
are difficult to fully implement, sustain and replicate, due to
competing interests and current hospital cultures. In a geri-
atric hospital, every single hospital process, and in turn
hospital-wide culture, would be based on the needs of frail
older adults, with an acute awareness of the potential risks of
negative outcomes associated with hospitalization. Key
structural designs would improve mobility while maintaining
safety. Although there are challenges to the development,
management and success of a geriatric hospital, these chal-
lenges present opportunities for innovative solutions which
would help advance the standards of hospital care of frail
older adults.
Acknowledgments
The authors would like to thank Dr. Muriel Gillick whose advice and
review of the paper were extremely helpful. We are also grateful to
her for her original article 20 years ago on this topic. We would also
like to thank Mengyang Zhang for her architectural drawing of the
semicircular units in proposed Geriatric Hospitals.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, au-
thorship, and/or publication of this article.
ORCID iD
Joseph H. Flaherty  https://orcid.org/0000-0003-4338-8810
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